- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,936.65 / $1,936.65 / $2,674.41
| Facility | | $1,936.65 | $1,936.65 | $2,674.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $922.21 / $1,829.05 / $1,936.65
| Professional | | $922.21 | $1,829.05 | $1,936.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $999.06 / $1,158.91 / $2,757.41
| Facility | | $999.06 | $1,158.91 | $2,757.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,383.32 / $1,921.28 / $1,921.28
| Facility | | $1,383.32 | $1,921.28 | $1,921.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.54 / $922.21 / $1,537.02
| Professional | | $645.54 | $922.21 | $1,537.02 |